Form 8038-TC Reporting Authority Issuer's name (Rev. November 2012) Department of the Treasury Internal Revenue Service Information Return for Tax Credit Bonds and Specified Tax Credit Bonds Under Internal Revenue Code section 149(e) See separate instructions. OMB No. 1545-2160 Part I 1 3 Check if Amended Return 2 Issuer's employer identification number (EIN) 4 Report number (For IRS Use Only) Name of person (other than the issuer) with whom the IRS may communicate about this return (see instructions) 5 Number and street (or P.O. Box if mail is not delivered to street address) 6 City, town, or post office, state, and ZIP code 7 Date of issue (MM/DD/YYYY) / 8 Name of issue 9 CUSIP number / 10 Name and title of officer of issuer whom the IRS may call for more information (see instructions) 11 Telephone number of officer or other person Part II 1 2 3 4 5 a b c d e f 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 1a b c d 2 3 4 5 6 7 8 9 Type of Issue . . . . Tax Credit Bond Code (See instructions, enter three digit code for the type of issue) . . . . . Description: Has the issuer made an irrevocable election to apply section 6431(f)? Yes No / / Enter the first interest payment date (MM/DD/YYYY) Interest payment date frequency (Check box; see instructions and attach debt service schedule): annual, semi-annual, quarterly, monthly, or other If line 5e above is checked, please describe the payment frequency: Part III Description of Obligations . . . . . . . . . . . . . . ............. ............. / / .............. .............. 6 ............ ............ 7 Enter the frequency rates are reset 8b 1 2 4 5 . . Amount 1 2 3 4 5 6 7 Amount 1a . . % years % % . Issue price . . . . . . . . . . . . Stated redemption price at maturity . . . . Final maturity date (enter date MM/DD/YYYY) Applicable credit rate . . . . . . . . . Maximum term . . . . . . . . . . . Permitted Sinking Fund Yield . . . . . . Enter the interest rate on the bonds . . . . If the issue is a variable rate issue, check box 8a Part IV Proceeds of Issue (Including underwriters' discount) Sale Proceeds . . . . . . . . . . . . . . . . . . . . . . . . . . . Proceeds used for bond issuance cost (including underwriters' discount) . . . . . . . . Estimated investment proceeds . . . . . . . . . . . . . . . . . . . . . Expected available project proceeds (Subtract line 2 from line 1 and add line 3) (see instructions) (For IRS Use Only) . . . . . . . . . . . . . . . . . . . . . . . . . . Other (describe) Total proceeds (Add lines 4 through 6) . . . . . . . . . . . . . . . . . . . Part V Description of Use of Proceeds for Qualified Purpose Expenditures Loans to qualified borrower(s) . . . . . . . . . . . . . . . . . . . . . . If a written loan commitment was obtained prior to issue date, check box Name of borrower (Attach list if more than one) EIN of borrower Land . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Buildings and structures . . . . . . . . . . . . . . . . . . . . . . . . Furniture or equipment with recovery period of more than 5 years . . . . . . . . . . Furniture or equipment with recovery period of 5 years or less . . . . . . . . . . . Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Demonstration projects . . . . . . . . . . . . . . . . . . . . . . . . Public education campaigns . . . . . . . . . . . . . . . . . . . . . . Repairs or other rehabilitation expenditures ................. Cat. No. 53394V 2 3 4 5 6 7 8 9 Form 8038-TC (Rev. 11-2012) American LegalNet, Inc. www.FormsWorkFlow.com For Paperwork Reduction Act Notice, see separate instructions. Form 8038-TC (Rev. 11-2012) Page 2 Description of Use of Proceeds for Qualified Purpose Expenditures (Continued) 10 11 12 13 14 15 16 17 Developing course materials and/or staff training expenditures . Pay principal, interest, or premiums on qualified bonds . . . . Refinance a qualified indebtedness . . . . . . . . . . Other (describe) Total qualified purpose expenditures (Sum of lines 1a through 13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 11 12 13 14 . 16 17 Amount . . . 1a % Percentage of total proceeds to be used for qualified purpose expenditures (Divide line 15 14 in Part V by line 7 in Part IV, multiply result by 100) . . . . . . . . . . . . If some portion of proceeds was used to reimburse issuer for amounts paid for a qualified purpose, enter the amount of reimbursement . . . . . . . . . . . . . . . . . If some portion of proceeds was to reimburse issuer for amounts paid for a qualified purpose, enter the date the official intent was adopted (MM/DD/YYYY) / / Part VI Allocation of National, State, Tribal, or Local Bond Limitation Amount (Enter source and amount of allocation and attach copy of certificate) . . . . . . . . . . . . . . . . . . . . . . . . . . 1 a Volume cap allocation amount . . . . . . . . . . . . . . Year of Allocation . . . . . Amount of Carryforward . b National, check box . . . . . . . Local, check box c State, check box . . . . . . . . . . . . . . . . . . d Tribal, check box . . . . . . . . . . . . . . . . . . 2 If box 1c is checked, enter State abbreviation . . . . . . . . . Part VII 1 Miscellaneous Arbitrage questions: a If there is a reserve or sinking fund that is expected to repay the issue at maturity, check box . . . . . . . . . b If 1a is checked and the reserve or sinking fund is funded in equal periodic installments, check box . . . . . . . c If either the funding of the reserve or sinking fund is expected to result in an amount greater than the amount necessary to repay the issue; or, if the yield on such fund is greater than the permitted sinking fund yield from line 6, Part III, check box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d If the issuer established written procedures to monitor the requirements of section 148 with respect to these bonds, check box .................................... 2 If all federal, state, and local requirements governing conflicts of interest are satisfied with respect to this issue, check box . . 3 If the entitlements to credits with respect to this bond issue are expected to be stripped, check box . . . . . . . 4 If the issuer established written procedures to ensure that all nonqualified bonds at the end of the applicable period are redeemed within 90 days, check box . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Other: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Un